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  LEGG CALVE PERTHES DISEASE ByAbdulrahman Sheha
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  Definition Idiopathic avascular necrosisof the proximal femoral epiphysis in children.
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  Epidemiology • ages 4-8years • 1 in 10,000 children • Boys:Girls= 5:1 • Usually unilateral • Higher among lower socioeconomic class
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  Etiology • IDIOPATHIC a. Disruptionof the vascularity of the capital femoral epiphysis. b. Hydrostatic pressure theory. Reactive synovitis > capsular distension > compression on retinacular vessels c. passive smoking (affects fibrinolysis)
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  Risk factors • Shortstature with delayed bone age (usually by two years). (90%) • Parents of the effected children are often elderly • Low birth weight babies • Associated congenital anomalies • Protein C & S def.
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  Presentation • Age 4-9years. • Intermittent pain in hip and a limp • insidious onset • Nature of pain : Aggravated by movement reileved by rest • limp and pain in the groin, hip, commonly thigh, or knee (referred pain).
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  Physical exam. • Abnormalgait (antalgic). • Decreased abduction and internal rotation. • Late Limb-length inequality, is mild due to femoral head collapse. • Trendelenberg positive
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  Diagnostic tests • XRay (Best) • Standard AP and frog-leg lateral views of the pelvis • according to the stage
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  Radiographic stages (Waldenstrom) a-Necrosis.(Ischemia stage). 6 months b-Fragmentation (Revascularization) 6 months c-Re ossification (healing) 18 month d-Final (Remodeling) 3 years Age at diagnosis is the most important prognostic factor
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  a-Early stage (Ischemiastage) • Widening of the joint space and minor subluxation • Irregular physeal plate
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  b-Fragmentation (Revascularization) • Fragmentationand focal resorption of the epiphysis. • subchondral # (Crescent sign)
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  c-Reossification (healing) • Normalbone density returns • Alterations in shape of femoral head and neck evident
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  d-Final (Remodeling) • Changesdepend on the severity the femoral head • Coxa magna
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  Late Stage • CoxaMagna. • High-riding trochanter. • Flattened femoral head. • Irregular articular surface.
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  Classification The Herring (lateralpillar) classification (most accurate) • height of the lateral pillar of the capital epiphysis on the AP view Group A: Normal height Group B: >50% maintained. Group C: <50% maintained.
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  Cont. (Herring)
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  Treatment Most patients (60%)with LCPD will NOT require surgical treatment. Conservative (mainstay of management). NSAIDs, painkillers, physiotherapy. In patients with: • Herring group A disease in any age group. • Young age (< 6 years) at the onset of disease.
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  Cont. Patients with poorprognosis will usually need containment • >6 years old at the onset of the disease • Female: mature earlier with less remodeling potential • Obesity • Progressive loss of hip motion • Advanced stage of disease at diagnosis (B, C) • Advanced grade (loss of containment).
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  Complications of Perthesdisease. a. Femoral head deformity. * Premature physeal arrest patterns * Osteochondritis dissecans, * Labral injury, and * Late osteoarthritis. b. The most important prognostic factor 1- Shape of the femoral head and its congruency at skeletal maturity 2- patient age at onset of disease. c. Degenerative changes in the hip joint in the fifth or sixth decade of life.